Responsible for the development, implementation and oversight of quality of care policies/programs and clinical guidelines.
Quality Improvement includes the following key areas: Population Health Management and Informatics, Quality Performance Management (clinical quality rates and surveys), Facility Site Review, Quality Improvement Initiatives, Provider Quality Review, Health Information Management, Performance and Incentives, and Accreditation & Oversight.
This position will implement strategy for the quality improvement functions within the health plan, in collaboration with the administrative and clinical leaders of the organization. The position oversees the tracking and presentation of results of improvement efforts and ongoing measures of clinical processes; oversees regulatory readiness, quality measurement, and pay for performance programs and initiatives. The position is responsible for directing current network performance improvement programs and establishing new improvement activities, including methods to track peer review, credentialing and provider performance improvement plans, site surveys and potential clinical quality and critical events reviews.
This position is responsive to the needs of the Chief Medical Officer and the Board of Governors subcommittees for Compliance & Quality and Children’s Health Collaborative Advisory Committee (CHCAC). The position will lead and act as an advisor to Credentialing and Peer Review Committee, Provider Quality Review and Clinical and Member Advisory Groups, and serve as liaison to various provider focused departments such as Credentialing and Provider Network Management in establishing and maintaining best practice operations for provider quality in efforts to ensure excellent member experience and access to care.
Forges strong relationships and continuing communication links with other providers, medical directors, Board members and the local community, including internal and external equity efforts.
Responsible for directing peer review activities including chairing the Credentialing and Peer Review Committee, and managing the Potential Quality Issues process.
Chair for Performance Improvement Collaborative Committee / Physician Quality Committee
Works with senior leadership in deploying standardized evidence-based best practices in medicine and clinical content and ensure adoption of best practices.
Ability to review and assess clinical cases for potential quality issues and legal cases for assessment of severity and actions necessary
Ability to work effectively and collaboratively in a diverse community and workplace through partnering, coaching, and teamwork
Other important qualities include excellent communication skills, negotiation skills, consensus building, analytic ability, planning and implementation skills, excellent interpersonal skills to develop and maintain critical internal and external relationships and motivate staff to achieve goals and objectives
Ability to communicate effectively in both oral and written form to a widely diverse audience ranging from unskilled staff to highly trained and experienced professionals.
Must maintain current competency in provider quality regulations and standards.
Experience with Credentialing and Peer Review, identifying and selecting appropriate actions for network member safety and provider quality.
Informatics and Analytic experience with quality data from multiple disparate sources.
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